2022 Erie Mercer Venango MA Kit

My Prescription Drug Coverage My plan has prescription drug coverage:  Yes  No If “yes,” here’s what I should know about my prescription drug plan: • The cost di erence between preferred, mail-order, and standard pharmacies • Formulary tier levels • Drug stages and how they impact your costs My current medications are: Medication: Has Limits (circle) _______________________________ Yes * / No _______________________________ Yes * / No _______________________________ Yes * / No _______________________________ Yes * / No Out-of-network/Noncontracted providers are under no obligation to treat UPMC for Life members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of- network services. UPMC for Life has a contract with Medicare to provide HMO, HMO SNP, and PPO plans. The HMO SNP plans have a contract with the PA State Medical Assistance program. Enrollment in UPMC for Life depends on contract renewal. * For medications that have limitations, I may need to contact the plan before I can fill my prescription. Y0069_221001_C Copyright 2021 UPMC Health Plan Inc.All rights reserved. 2022_ENRLRCPNWPAPRM_21MCID1939 (MS) 7/1/21 126